Healthcare Provider Details

I. General information

NPI: 1730712308
Provider Name (Legal Business Name): JAKE B BLOOM LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 KOTHLOW AVE
MENOMONIE WI
54751-3090
US

IV. Provider business mailing address

803 BALLENTINE RD
MENOMONIE WI
54751-3740
US

V. Phone/Fax

Practice location:
  • Phone: 715-235-4537
  • Fax: 715-235-4535
Mailing address:
  • Phone: 715-505-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4058-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: